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What Is “First Pass Success” Anyway? Defining Outcomes That Matter in Airway Research

June 2, 2023

Written by Aaron Lacy

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These authors propose that the definition of a successful first attempt during intubation should be placement of an endotracheal tube (ETT) in the trachea after a single insertion of a laryngoscope followed by a single ETT insertion.

Why does this matter?
First attempt success in intubation is often used as a primary outcome and benchmark of quality when studying endotracheal intubation (ETI). There has been no consensus definition of first attempt success during ETI.

Intubation is serious, so set a high standard
Historically, first attempt (pass) success was defined by successful passage of the ETT during a single laryngoscope insertion. However, this definition doesn’t account for possible repeated tube deliveries. Given that most intubations are now done with video laryngoscopy, in which obtaining a glottic view is easier, tube delivery is often the rate limiting step to a successful ETI. The authors propose a stricter definition of first attempt success: single blade insertion followed by single ETT insertion.

The authors applied this stricter definition of first attempt success to two prior large multicenter airway trials (BOUGIE and PREPARE II). When looking at 1,863 ETIs and applying the strict definition, overall first attempt success decreased by 4.9% (86.0 to 81.2; 95% CI 2.5-7.3) and decreased median duration of intubation by 35 seconds (95%CI 8.9-61.1). This is a significant difference when reviewing the results of these landmark trials.

While intuitively this makes sense, not all studies reporting first attempt success utilize this definition. Going forward, I agree with these authors that when reporting intubation success, we should define first attempt success this way. This is the highest marker of quality and would allow for standardization and a common language among researchers and a common understanding for readers.

Defining successful intubation on the first attempt using both laryngoscope and endotracheal tube insertions: a secondary analysis of clinical trial data.  Ann Emerg Med. 2023 Apr 17;S0196-0644(23)00213-5.

What are your thoughts?